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Personal Information
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First Name:
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Please supply your first name
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Last Name:
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Please supply your last name
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Email Address:
(This email will serve only as your username when logging into your account.)
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Please supply your emailNot a valid email
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Confirm Email:
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Please supply your email againEmails do not match
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Password:
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Please supply your passwordYour password must be atleast 6 characters long
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Confirm Password:
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Please supply your password againPasswords do not match
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Phone Number:
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Please supply your phone number
Please supply a valid phone number. Ex. (519) 123-4567
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Address:
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Please supply your address
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Postal Code:
ex. A1A 1A1
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Please enter your postal code
Please supply a valid postal code. Ex. A1A 1A1
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How did you hear about us? (Optional)
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?
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Do you consent the collection, use and disclosure of your personal information as per our brokerage privacy policy? View Privacy Policy
You must select Yes to proceed.
Please select Yes or No.
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This question confirms that you, the client, hereby acknowledges that the Broker has been retained by the client to acquire or renew a policy or policies of insurance or to provide Consulting and/or Risk Management Services for the Client, under which the individual Client, or named individuals in addition to the Client, or where the Client is a commercial or other entity, its employees, servants and representatives (hereafter collectively called "insured individuals") may be insured.
As part of the application for new or renewal insurance coverage(s), the Client hereby authorizes the Broker to collect, use and disclose personal information of such insured individuals as required and as permitted pursuant to relevant privacy laws or other laws.
The Client hereby expressly consents to the Broker collecting, using or disclosing personal information of such individuals, or providing such personal information to third parties as required, including insurance companies. Where there are insured individuals in addition to the Client, or where the Client is a commercial or other entity, the Client hereby covenants and warrants that the Client has obtained the appropriate consent from all the insured individuals to disclose their personal information to the Broker for these purposes accordingly. For additional information please contact our privacy officer.
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Group Code(optional):
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